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Case note review
Case note review Death under anaesthetic during hip surgery associated with intraoperative bleeding Case summary A patient in her mid-80s was admitted to hospital with active shingles, a urinary tract infection, general deconditioning and mobility issues. Six weeks after transfer to the rehabilitation ward she suffered a fall, resulting in a Vancouver C periprosthetic fracture between a previously revised hip replacement and a knee replacement. The patient had an extensive medical history. She suffered from osteoarthritis, hypertension, chronic obstructive pulmonary disease (COPD), recurrent urinary tract infections and gout. She had had an internal iliac artery aneurysm five years previously and more recently had undergone aortic valvuloplasty, after which she was suspected to have had a cerebrovascular accident (CVA). A history of deep vein thrombosis (DVT) had been without incident for the past 35 years. She had previously been diagnosed with disseminated breast cancer, which resulted in a mastectomy, three cycles of poorly tolerated chemotherapy followed by radiotherapy, and continuing treatment with anastrozole. She was in remission for a splenic marginal zone lymphoma,
for which she had received chemotherapy four years earlier. She was on multiple medications, including clopidogrel, ferrous sulphate, enoxaparin and strong analgesia. The day after her fall, the patient was admitted to the orthopaedic unit (following communication between the medical officer and Orthopaedic registrar). Her previous CVA (three months before admission) was noted, as were her current medications, although the plan regarding DVT prophylaxis was hard to determine given the poor legibility of the notes. Drug chart review indicated that enoxaparin (40mg) was administered the day after the fall. Two days after her fall, the patient went into atrial fibrillation. A coagulation profile performed the same evening was within normal limits regarding prothrombin, INR (international normalised ratio) and APTT (activated partial thromboplastin time). None of these measures indicate the effectiveness of enoxaparin, which requires an anti-Xa assay, which is not routinely done.
The patient’s haemoglobin level was noted to be 67g/L when reviewed by the after-hours resident medical officer two days after the fall. A haematology review was advised for the following morning but there is no record of this consultation in the case notes. The patient was not seen by an Orthopaedic resident until two days after her transfer to the Orthopaedic unit. She had been catheterised, and it was noted in the early hours that her urinary output decreased then increased after a bolus of 200ml of fluid. It was noted at that time that the patient also suffered from congestive cardiac failure. Her fracture was un-displaced, and it was not until two days after the fall that gentle traction was prescribed. At surgery (three days after the fall), the exposure was uncomplicated; all bleeding points would have been controlled. The attempted reduction of the fracture was difficult. The intent, from the preoperative plan, was to use a plate, screws and cables, plus an allogenic cortical strut graft. The case notes
